Accreditation 2023 - Communication

Medication Reconciliation by Bonnie Smith, RPhT

Medication reconciliation process is the beginning of medication safety for a patient/client in hospital; often there are differences between the medications they take at home and those ordered upon admission to hospital. Many of these discrepancies have the potential to result in adverse drug events.

Upon or prior to admission, medication reconciliation begins. A Best Possible Medication History (BPMH) is taken which lists all the medications the client is taking including prescription, non-prescription, holistic, herbal, vitamins and supplements. The BPMH also details how they are being taken including the dose, frequency and route of administration. Creating the BPMH involves interviewing the client, family, or caregivers and consulting at least one other source of information. 

Once generated, the BPMH is an important reference tool for reconciling medications at care transitions and may be used to generate admission medication orders. When the BPMH and the admission medication orders are compared, any medication discrepancies are identified, resolved and documented.

At Pembroke Regional Hospital (PRH), all patients admitted to the hospital, including admission through the Emergency Department, Pre-Operative Assessment Clinic or direct transfer in from another institution, all have medications reconciled.

Medication reconciliation by our BPMH pharmacy technicians or heath care professional at admission is achieved using one of two models; dependent on resource availability.

• In the proactive model, the BPMH is used to generate admission medication orders. The admitting physician or most responsible physician (MRP) completes the medication reconciliation and physician orders within 48hours- using the BPMH to create admission orders.

• In the retroactive model, the BPMH is generated after admission medication orders have been written; a timely comparison of the BPMH and admission medication orders is then made.  

Regardless of the model used, it is important to identify, resolve, and document medication discrepancies. When discrepancies are identified between the BPMH and admission orders, the pharmacy department notifies the clinical pharmacist or MRP. Click here to collect the Q-Tip.

At care transitions, in addition to the medications the client is currently receiving, it is important to also consider the medications that were taken prior to admission (as identified in the BPMH), which may be appropriate to continue, discontinue, or change.

For example, medication reconciliation should happen at discharge or when medications are changed or reordered as part of a transfer involving a change in the service environment (e.g., from critical care to a medicine unit, or from one facility to another within an organization). Medication reconciliation is not required for bed relocation. 

During their stay at the hospital, patients should be regarded as active partners in the management of their medications and provided with information about the medications they should be taking in a format and language they understand. They should be encouraged to keep an up-to-date medication list and share it with their providers. 

PRH follows the "Medication Reconciliation" policy and uses either a "Pharmacy generated BMPH" or "Medication Order Form and Best Possible Medication History" form found within the policy and procedure manual. 

To learn more about Medication Reconciliation, or if you have questions about the process, call the Pharmacy at extension 6168.